HEALTH

CAUSES/RISK
ALTERATIO FACTORS
N

SYMPTOMS

DIAGNOSI NURSING
S
ACTIONS/
TREATMENT

SLEEP
DISORDERS

CAUSES:
- BPH
- HEART FAILURE/ANGINA
- OVERACTIVE
BLADDER/DIURETICS
- GERD
- COPD
- RESTLESS LEG
- SLEEP APNEA
MUSCULOSKELETAL/ARTH
RITIS PAIN
ANXIETY/DEPRESSION/DE
MENTIA

- FORGETFULNESS
DISORIENTATION/CONF
USION
- COGNITIVE
IMPAIRMENT
RESTLESSNESS/WANDE
RING/ FALLS
- DEPRESSION
- SUNDOWNER
SYNDROME
- USE OF OTC SLEEP
AIDS

SLEEP
ASSESSMENT:
- SLEEP
HISTORY
- BEDTIME
PATTERNS AND
RITUALS
- AMOUNTS
AND TIMES OF
SLEEPS/NAPS
- SLEEP
ENVIRONMENT
- TOILETING
NEEDS DURING
TIMES OF
SLEEP
- MEDICATION
REVIEW WITH
PRESCRIPTION,
OTC, AND
HERBS

- NORMALIZE SLEEP
PATTERNS/RITUALS
- EVALUATE/TREAT
UNDERLYING
PROBLEMS
- TIME MEDICATIONS
APPROPRIATELY
- AVOID STIMULANTS
BEFORE SLEEP
- NATURAL LIGHT IN
THE AFTERNOON
- ROUTINE
EXERCISE/ACTIVITY
- EXTREME CAUTION
WITH
MEDICATIONS/SIDE
EFFECTS

PROBLEMS
EATING OR
FEEDING

CAUSES:
DETERMINES
- D DISEASE
- E EATING POORLY
- T TOOTH DECAY/PAIN
- E ECONOMIC HARDSHIP
- R REDUCED SOCIAL

- ORAL CAVITY
CHEILOSIS
- EYES SCLERAL
CHANGES, BITOTS
SPOTS
- FACE SEBORRHEALIKE DRYNESS;

- EXAMINE
MOUTH/ORAL
CAVITY/SKIN
- EVALUATE
SERUM
ALBUMIN,
HEMOGLOBIN,

- PREVENT
DEHYDRATION
- PREVENT
FOOD/DRUG
INTERACTIONS
- INVOLVE FAMILY
AND OLDER ADULTS

PAIN

CONTACT
- M MULTIPLE
MEDICATIONS
- I INVOLUNTARY WEIGHT
LOSS/GAIN
- N NEEDS ASSISTANCE
WITH SELF-CARE
- E ELDERLY
S SENSORY IMPAIRMENT

REDNESS OF
NASOLABIAL
FOLDS/EYEBROWS
- UPPER EXTREMITIES
PURPLE BLOTCHES,
CELLOPHANE SKIN
- LOWER EXTREMITIES
FLAKING, CRACKING
- ABDOMEN/BUTTOCKS
WAXY,
HYPERKERATOSIS

CAUSES/TYPES:
- ACUTE
- CHRONIC

- ANXIETY
- FUNCTION
- SOCIAL

B12, IRON,
TRANSFERRIN
LEVELS
- ASSESS
MEDICATION
REGIME
- REVIEW COMORBIDITIES
- COMPARE TO
USUAL WEIGHT
- OBTAIN 5-7
DAY DIET
HISTORY
- LOOK FOR
PATTERNS,
PREFERENCES,
PERCENTAGES
- DETERMINE
SOCIOECONOM
IC AND
CULTURAL
FACTORS
- USE MININUTRITIIONAL
ASSESSMENT
OR
NUTRITIONAL
SELFASSESSMENT
CHECKLIST
- ASSESSMENT
- PAIN IS WHAT
THE PATIENT

- RESOLVE FEEDING
OR ENVIRONMENTAL
PROBLEMS
- USE COMMUNITY
RESOURCES
- INVOLVE DIETICIAN
IF APPLICABLE
- CONSIDER
APPETITE
STIMULANTS

PHARMACOLOGIC:
- 48 DRUGS IN
BEERS CRITERIA

INTERACTION
- DEPRESSION

INCONTIENC CAUSES:
- PELVIC FLOOR LAXITY
E
URGE DUE TO
DETRUSOR
IRRITABILITY
AND ABNORMAL
BLADDER
CONTRACTION
STRESS DUE
TO REDUCED
SPHINCTER

- CONSTIPATION OR
IMPACTION
- DIABETES MELLITUS OR
INSIPIDUS
- SPINAL CORD
INJURY/NEUROLOGIC
DISEASE
- 3 DS
- RESTRICTED MOBILITY
- INFECTION
- ATROPHIC
VAGINITIS/URETHRITIS

SAYS IT IS.

- PROPOXYPHEN
- MEPERIDINE
- MIXING
ANALGESICS
- NSAIDS

NONPHARMACOLOGIC:
- CONTINUOUS
NERVE STIMULATION
- DISTRACTION
- RELAXATION
- BIOFEEDBACK
- IMAGERY
- HYPNOSIS
- PHYSICAL ACTIVITY
-EXERCISE
PROGRAMS
- DO YOU HAVE - KEGALS
FREQUENCY,
- ADJUST FLUID
URGENCY,
INTAKE
BURNING?
- AVOID CAFFEINE,
- DO YOU LEAK ALCOHOL, NICOTINE
WITH SNEEZE
- PREVENT
OR COUGH?
CONSTIPATION
- HOW OFTEN
- ADJUST
DO YOU
MEDICATION TIMING
URINATE AT
- TREAT INFECTIONS
NIGHT?
- CHANGE
- DO YOU LIMIT ENVIRONMENT
FLUIDS OR NOT - BLADDER
TAKE DIURETIC RETRAINING
MEDS?
- URODYNAMIC

RESISTANCE
AND SUDDEN
ABDOMINAL
PRESSURE
(SNEEZE/COUG
H)
OVERFLOW
BLADDER
DISTENTION
EXCEEDS
OUTLET
RESISTANCE

- PROSTATE PROBLEMS
- FLUID, ALCOHOL,
CAFFEINE INTAKE
- UROLOGICAL OR GI
SURGERY
- MEDS:
ANTICHOLINERGIC,
DIURETICS, NARCOTICS

- DO YOU LEAK
WHILE
GETTING TO
THE TOILET?
- DO YOU PLAN
AROUND
BATHROOM
AVAILABILITY?
- DO YOU
WEAR A PAD?

EVALUATIONS
- SURGERY
- COLLAGEN
INJECTIONS
- CLAMPING
DEVICES
- PESSARY
PLACEMENT
- MEDICATIONS

- HEINDRICH II
FALL RISK
MODEL
- TIMED GET
UP AND GO
TEST (TUG)
- ASSESS
MULTI-SYSTEM

- EVALUATE
MEDICATIONS
- LIFESTYLE
CHANGES
PHYSICAL/OCCUPATI
ONAL
THERAPY/EXERCISES
- FALL PROOF THE
ENVIRONMENT

FUNCTIONAL
PHYSICAL OR
PSYCHOLOGICA
L INABILITY TO
REACH THE
TOILET

CONFUSION
EVIDENCE
OF FALLS

SEE COGNITIVE CHANGES

CHART *
- MEDICATION EFFECTS
- SENSORY DEFICITS
- PHYSICAL CHANGES
- COGNITIVE CHANGES
- ENVIRONMENTAL
HAZARDS

SKIN
BREAKDOW
N

PAIN
INFECTION
SEPSIS

BRADEN RISK
ASSESSMENT